HomeMy WebLinkAbout218 - 222 1/2 HAMMOND AVEExemption year: (J[ V6 'd(il9
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Applicant's Name:
Billing Address:
Address of Exemption:
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Date
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Water Works Account No.:
1 request an exemption from Garbage Fees during the cur -" Calendar Year. I
employ the services of a licensed trash hauler. Only o locatio where the
trash hauler picks up garbage and trash will qualif fothe ex tion.
Applicant' Signature
TO BE OMPLETED Y LICEN
(We) W., OV
C:mpany
AGE AND TRASHdHAULER:
hereby declare that we are
a licensed trash hauler in the City of Waterloo, Iowa, and that we pick up
garbage and refuse at the following location:
Beginning Ending
Address Location of Date of Date of
Ctomer's Name Garbage/Trash Pick -Up Contract Contract
P11 SGC 40,01$22odO .i, ls Iy i)h //V
- 3
CONTRACT PERIOD MUST COVER AT LEAST CURRENT CALENDAR YEAR
We understand that the above information is used by the Clerk's Office in
Waterloo, City Hall, 715 Mulberry Street, to determine eligibility for
exemption from garbage fees for the current calendar year. I the
undersigned, declare under penalty of perjury that I have examined this
claim, including all statements and above schedule, and to the best of my
knowledge and belief, it is a TRUE, CORRECT AND COMPLETE claim, and that I
agree to comply with all ordinances asci policies of the City of Waterloo and
the Black Hawk County Solid Waste Commission.
In the event that the above person discontinues service with said company
during the current calendar -:r, we hereby agree to notify the Clerk's
Office of this event by calli . 291-4323.
Date
007-
S'gna
e of Auth
ed Company Representative
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/cam
omp. ' address
Garbage & Trash Eauler's Permit License
(issued by Black Hawk County)
PLEASE RETURN TO: CITY CLERK & FINANCE OFFICE
715 MULBERRY STREET
WATERLOO, IOWA 50703
City Clerk's Copy - white Customer's Copy - yellow